The practice of medicine is increasingly characterized by overwhelming amounts of information, new knowledge in diagnostics and therapeutics, and highly fragmented care environments, with potentially hundreds of different individuals delivering care to a single patient across healthcare settings. Coordinating clinical decisions to advance the care and treatment of patients within this environment poses significant challenges. Hospital readmission is an important example of the type of problems health systems face in allocating critical resources in the midst of this fragmented environment.
Many patients are unnecessarily readmitted to the hospital. A 2009 study published in the New England Journal of Medicine (Jencks, S. F., et al., “Rehospitalizations among Patients in the Medicare Fee-for-Service Program,” The New England Journal of Medicine, 360 (2009): 1418-28) demonstrated that almost one-fifth of Medicare patients were readmitted to the hospital within 30 days of discharge and 34% were readmitted within 90 days. This research estimated that only 10% of these readmissions were planned and that the annual cost to Medicare alone of unplanned hospital readmissions exceeds $17 billion.
For example, patients with heart failure, the leading diagnosis for acute care hospitalization and readmissions for patients over the age of 65, face particular challenges in transitioning from the hospital to home, and hospital readmissions are common for these patients. Preparation for discharge is often fragmented, and many patients and families feel ill-prepared for discharge. Upon discharge, responsibility for management of patients reverts back to their primary care provider, who may have no record of the care or medications given during the hospital stay. This lack of coordinated care results in frequent readmissions, with a large percentage of patients discharged with heart failure being readmitted to the hospital within several months.
While not all readmissions are preventable, it is estimated that a significant percentage of heart failure readmissions is avoidable with better patient education, better communication with the patient and the patient's primary care provider, ensuring that the patient has appropriate follow-up scheduled at the time of discharge, and other targeted intervention and treatment. However, most hospitals fail to consistently implement most or all of these elements. Many interventions can be expensive and complicated to perform in the real world. One of the reasons why efforts can fail is that hospitals have difficulty identifying patients that are truly at risk for readmission and for which interventions should be a high priority.
If high-risk patients could be more easily and accurately identified early in their hospital stay (e.g., in the Emergency Room or upon admission), the right interventions could be performed on the population for which it is most needed, thereby lowering overall heart failure readmission rates. Today, most hospitals attempting to identify patients at risk are doing so manually, without leveraging the information available in their electronic health records. Hospital readmission is one of potentially thousands of adverse clinical events that could be prevented by electronic identification, targeting, coordinating and monitoring throughout the inpatient and outpatient environment. This disclosure describes software developed to identify and risk stratify patients at highest risk for hospital readmissions and other adverse clinical events.